Shoulder Impingement Surgery

Introduction

Shoulder Impingement Surgery, also know as Arthroscopic Acromioplasty may be used to treat shoulder pain. Shoulder pain is a common physical complaint and the rotator cuff is a frequent source of pain in the shoulder.

The shoulder is made up of 3 bones:

  • Humerus – Arm bone.
  • Scapula – Shoulder blade.
  • Clavicle – Collar bone.
The rotator cuff is a combination of 4 muscles with tendons that surround the top part of the shoulder blade. These muscles are:
  • Supraspinatus.
  • Infraspinatus.
  • Subscapularis.
  • Teres minor.

The function of the rotator cuff is to attach the humerus to the scapula and assist in lifting and rotating the arm.

The bursa (lubricating sac), situated between the rotator cuff and the bone on top of the scapula (acromion), allows the rotator cuff tendons to move freely when you move your arm.

Shoulder impingement occurs when the supraspinatus tendon rubs on the under-surface of the acromion.  As the tendon continues to catch it causes further inflammation (which may involve the subacromial bursa) and the pain worsens. This also leads to an imbalance of shoulder movements from overuse of the other muscle group, leading to the pulling of the humeral head upwards and further narrowing of subacromial space and increased impingement.

Rotator cuff pain is common in both young athletes and middle aged people. Those vulnerable are people who do repetitive overhead activities such as athletes (swimmers, tennis players and baseball players) as well as worker related occupations such as painters and construction workers.

The condition may come on gradually or acutely and result from an acute injury or overuse or from no apparent cause.

The patient presents with:

  • Pain – Minor pain present with activity and rest and radiates from the front of the shoulder to the side of the arm. As the problem progresses there will be pain at night.
  • Weakness.
  • Loss of motion – Difficulty with activities with arms behind back such as fastening bra and zippering.

Non-surgical Treatment

The aim of treatment is to relieve pain and restore function. In most cases, non-surgical treatment leads to a full recovery in around 80% of patients.  

  • Rest – Avoid overhead activities.
  • Non-steroidal anti-inflammatory drugs – Drugs like Brufen, Nurofen and Celebrex reduce the pain and swelling.
  • Physiotherapy – A course of physical therapy aimed at rehabilitating and retraining the rotator cuff and scapula musculature with a theraband strengthening and stretching programme.
  • Steroid Injection – Usually an ultrasound guided injection of steroid and local anaesthetic into the bursa under the acromion can relieve pain.

Dr Lane will base his diagnosis on patient’s history and clinical examination. Patients often have local swelling and tenderness in front of their shoulder and may have pain and stiffness lifting the arm. Special tests such as X-rays and MRI scan can confirm the diagnosis. Although the X-ray cannot show soft tissues, it may reveal a small bone spur on the front edge of the acromion. This spur develops overtime and may aid in the development of a mechanical tear as well as prevent recovery from non-surgical treatment. A MRI scan can show fluid or inflammation in the bursa or tears in the rotator cuff.

Indications

  • Failure of non-surgical treatment.
  • Significant impairment or weakness.
  • Symptoms lasted 6 to 12 months.
  • Bony spur evident on X-Ray associated with bursitis and inflammation and damage to tendon.

Pre-operative patient education

If arthroscopic acromioplasty is recommended, Dr Lane will give his patients a comprehensive explanation of the procedure, expected recovery and surgical risks. Educational leaflets supplied by the Australian Orthopaedic Association are also supplied for patient information.

Pre-operative instructions

Non-steroidal anti-inflammatory drugs such as Feldene, Naprosyn and Celebrex should be stopped 5 days before surgery. These drugs increase the risk of bleeding. Aspirin or other blood thinning drug use prior to surgery should be discussed with Dr Lane. The shoulder to be operated on should be free of cuts, scratches or sores as this can increase the risk of post-operative infections. If there is damage to the skin, surgery will be postponed until healed.

Arthroscopic acromioplasty is usually performed as a day procedure although occasionally, the patient may stay overnight in hospital. The reception staff will give clear instructions about your admission location and time. Do not eat or drink 6 hours before your surgery.

Bring to Hospital:

  • List of medications.
  • Relevant X-rays or MRI scans.
  • Medicare, DVA or Private Health Care Cards.

Once your details have been taken in the admissions area:

  • The duty nurse will take your clinical details and baseline observations.
  • Theatre gown is given to wear.
  • The shoulder to be operated on will be inspected by the nursing staff, washed with anti-septic solutions and covered with sterile drape.
  • TED stocking will be given to wear to reduce the risk of deep venous leg thrombosis after surgery.

You will be taken to the theatre complex by the nursing staff and then into the anaesthetic bay where you will meet Dr Lane and your anaesthetist.

Procedure

Arthroscopic acromioplasty is the treatment of choice for shoulder impingement. It is performed under a General Anaesthetic when the patient is asleep, often in conjunction with regional nerve block which aids post-operative pain relief. A single dose of intra-venous antibiotics is given to the patient before surgery to reduce the risk post-operative infection.

When asleep, the patient will be positioned onto their side and weighted traction applied to the arm to hold it upwards thus allowing access into the shoulder joint. The shoulder, arm and upper chest is prepped with anti-septic solution and then the patient covered with sterile drapes with a window for the operative site.

A small fibre-optic camera (arthroscope) is introduced into the back of the shoulder joint through a small 1cm incision and the joint is evaluated for other causes that may be causing symptoms. The camera displays pictures on a television screen. Through this portal, saline-like fluids are introduced into the joint to expand it and give adequate vision. The arthroscopy is then placed into the subacromial space above the supraspinantus tendon. A second incision is made on the outside of the shoulder. A diathermy probe is then inserted to remove soft tissue (corico-acromial ligament) under the spur. A high- speed burr is then used to shave the spur and so create adequate space under the acromion for the supraspinatus tendon to glide.

The incisions are closed with either steri-strips or sutures depending on their size and dressed with primapore. Outer dressing is then applied. The arm is placed in a sling for comfort and should be worn for the next 1 to 2 weeks as needed.

After the procedure, you will be taken to recovery area. When adequately awake, observation stable, comfortable and able to eat and drink, the patient will be discharge. A script will be given for pain relief.

Post-operative Instructions

It is important to keep the dressings dry until see in Dr Lane's rooms 10 – 14 days after surgery. The outer bulky dressing can be removed after 3 days keeping the primpaore intact. Dr Lane will advise on passive exercise programme before being reviewed in his rooms in1 10 to 12 days after surgery. Following this visit, a course of physiotherapy is advised to aid recovery.

Risks

General Complications (rare)

  • Death.
  • Myocardial Infarction (heart attack).
  • Stroke.
  • Pneumonia.
  • Deep venous Thrombosis.
  • Blood loss.

Local Complications (uncommon)

  • Nerve injury – This typically involves the nerve that activates your deltoid muscle.
  • Infection – Patients are given antibiotics during the procedure to lessen the risk of infection.
  • Failure to achieve result.
  • Fracture.
  • Deltoid detachment.
  • Stiffness – Rehabilitation lessens the risk of stiffness.